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Disc Reduction

Disc Reduction

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Published by rapannika
A narrative review paper of the effect of McKenzie exercises, manipulation, and traction on movement of the nucleus of the lumbar intervertebral disk
A narrative review paper of the effect of McKenzie exercises, manipulation, and traction on movement of the nucleus of the lumbar intervertebral disk

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Published by: rapannika on May 07, 2009
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02/01/2013

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Introduction
“Disc herniation” is a collective term, describing aprocess in which the rupture of anular fibers allows fora displacement of the nucleus pulposus within the inter-vertebral space, most commonly in a posterior or poste-rolateral direction
1
. Weber
1
subdivides disc herniationsinto three categories: protruded, extruded, and seques-tered. He visualizes a protrusion as a bulging disc withthe anular wall still intact and an extrusion as a disc inwhich the nucleus pulposus has penetrated the outer anularfibers. With a sequestration, one or more fragments of the nucleus have broken free from the herniated massand have escaped into the spinal canal.All nociceptively innervated structures are theoreti-cally a source of pain if afflicted by an appropriate dis-ease or disorder
2
. Because the periphery of the disc isnociceptively innervated, the degenerative and/or trau-matic process of disc herniation may produce discogenicpain by excessive mechanical strain on the outer anularfibers
2
. Inflammatory products following trauma to theseanular fibers may cause pain by chemical irritation of the nociceptive nerve fibers
2
. Disc herniation can alsocause compression of nociceptively innervated extradiscalstructures, such as the posterior longitudinal ligament,the dural sleeves of the nerve roots, and possibly the duralcovering of the spinal cord
2
.Disc herniation can also cause radicular pain. Dor-sal root ganglia have been shown to be sensitive to me-chanical compression
2
(normal nerve roots are not sen-sitive to such compression
2
). However, the venous sys-tem of the nerve root is very vulnerable: even minor com-pression may lead to edema formation, resulting in in-traneural inflammation and making the nerve root highlymechanosensitive
1
. Penetration of the outer anular fibersmay also release endogenous chemicals from within thedisc, thus increasing nerve hyperexcitability and suscep-tibility to compression
1
; these chemicals may also causepain by chemical irritation of any other nociceptively
Address all correspondence and request for reprints to:Peter HuijbregtsSouth Haven Community HospitalRehab Dept.955 S. Bailey AvenueSouth Haven, MI 49090
Fact and Fiction of Disc Reduction: A Literature Review
 Abstract:
This article reviews research on the effects of manipulation
,
traction, and McKenzieexercises on the position of herniated nuclear material in lumbar intervertebral discs. Conclu-sions based on this research are discussed as well as clinical relevance and avenues for futureresearch.
Key Words:
Disc, Herniation, Manipulation, Traction, McKenzie
Peter A. Huijbregts, MSc, MHSc, PT, OCS, MTC, CSCS
The Journal of Manual & Manipulative TherapyVol. 6 No. 3 (1998), 137 - 143
Fact and Fiction of Disc Reduction: A Literature Review / 137
 
innervated structures with which they come into con-tact
2
.The goal of physical therapy with disc herniation (aswith any other disease or dysfunction) is to restore ormaximize patient function. Disc herniation is hypothesizedto result in the patients symptoms by mechanical or chemicalirritation of discal and extradiscal structures. Decreas-ing the mechanical component by restoring the displacednuclear material to its normal, or a more normal, placewithin the disc is one possible method for decreasingsymptoms and restoring function. Physical therapists useseveral interventions in the treatment of disc protrusionor extrusion, justifying these choices by stating theseinterventions may alter the position of nuclear material.This article reviews research on the ability of the physi-cal therapist to affect nuclear position in the lumbar spineby manipulation, traction, and McKenzie exercises. Toestablish the effect of such interventions on nuclear positionresearch uses imaging techniques that give informationon that nuclear position pre- and post-intervention, suchas epidurography, discography, CT scan and MRI. I willalso discuss possible conclusions drawn from these re-search findings, the relevance of these conclusions forphysical therapy practice, and suggestions for future research.
Manipulation
Spinal (thrust) manipulation can be a combinationof movements along any of the six degrees of freedom avertebra has for motion
3
. Most literature, however, dealswith rotatory manipulation. In this type of manipulation,emphasis is placed on a transverse plane rotation; how-ever, this does not exclude other translation or rotationfrom taking place.Wilson and Ilfeld
5
used a regional rotatory manipu-lation on 13 patients with disc herniation at L4-L5 orL5-S1 that had been confirmed on a myelogram. Imme-diately after the manipulation, a repeat myelogram wasdone; this showed no change in herniation in 12 patientsand an increase in one. During subsequent surgery, theanulus of this one patient was found to be intact. Theauthors stated that it is unlikely that an extrusion can bereduced by manipulation, but despite the findings in theirpatient with the larger herniation, manipulation may bebeneficial in patients with a protruded disc with a stillintact posterior anulus.Zhao and Feng
4
studied the effects of conservative treat-ment with segmental spinal manipulation on herniationsize and location using repeated CT images in 22 pa-tients with multi-level and 39 patients with single levelherniations. No changes were found in size and positionon CT with naked-eye examination in a total of 86 mo-tion segments, nor in volume with a computerized evaluationsystem in 27 patients with 38 affected segments. The authorshypothesized that studies that show reduced herniationfollowing manipulation may be flawed as a result of thenatural shrinkage of the extruded tissue over time, as aresult of different planes for pre- and post-interventionimaging, and even because forceful manipulation mayprogress an extrusion to a sequestration with migrationof disc fragments out of the plane of the post-interven-tion CT image.In a case study Zhao and Feng
6
describe the treat-ment of a 12 year old girl with a herniation of L5-S1,confirmed by both CT and MRI. Despite treatment withsegmental rotatory manipulation of the affected motionsegment and despite full functional recovery, no changeson CT scan 4 and 10.5 months after the initial onset of complaints were apparent.One hypothesis regarding the effect of rotatory ma-nipulation on the location of the herniated nuclear materialof an extrusion is that rotation may create a negativeintradiscal pressure that may “suck in” the herniation
4
.Rotation leads to tensile stresses in the anular fibersrestricting this motion. This tensile stress is transmit-ted to the nucleus contained within these fibers, result-ing in increased intradiscal pressure. This was confirmedby Nachemson
7
during in vivo measurements of intradiscalpressure: rotation led to increased intradiscal pressurein the L3-L4 disc when added to trunk flexion with weights.This increased pressure may very well lead to furtherextrusion of nuclear material through the anular tears.One might assume that tension generated in the outerstill intact anular fibers may affect the position of thenuclear material of a disc protrusion. Wilson and Ilfeld
5
reported on one patient with a larger herniation aftermanipulation. Contradicting their assumption that ro-tatory manipulation may be helpful in reducing nuclearmaterial in case of an intact anulus, as stated previously,this patient was found on subsequent surgery to have anintact anular wall.In conclusion, based on the research reviewed, thereis no proof to support the hypothesis that rotatory ma-nipulation will restore normal nucleus position in eitherdisc protrusion, or extrusion; nor is there evidence tosupport a differential effect of manipulation on protru-sion versus extrusion. In fact, rotatory manipulation maywell lead to further nuclear displacement. In the case of a protrusion, tensile strain to anular fibers as a result of rotation may further weaken the containment of the nucleus.The increased intradiscal pressure associated with rota-tory manipulation may well lead to an increased displace-ment of the nucleus in the case of disc extrusion.
Traction
Traction can be applied to the lumbar spine manu-ally or mechanically; in a supine, prone or inverted po-sition; in different degrees of trunk flexion or extension;with constant or intermittent force application; and usinga conventional table or a split-table. All applicable stud-ies used constant traction in a supine or prone position
138 / The Journal of Manual & Manipulative Therapy, 1998
 
on a conventional surface.Mathews
8
subjected two patients with disc protrusionsconfirmed on epidurography to 120 lbs of continuous lumbartraction while they lay prone on a conventional table. A46 year old female with protrusions between L1 and L4no longer showed any sign of disc protrusion onepidurography after 38 minutes of traction; repeatepidurography showed returning defects after 14 min-utes. Twenty days later symptoms recurred and theepidurography showed disc protrusions similar to the firststudy. The second patient, a 67 year old male, had aprotrusion at L3-L4, which was reduced after four min-utes of traction and even further reduced after 20 min-utes of traction. Ten minutes after release of the trac-tion, the protrusions were shown to have returned to 2/ 3 of their original size.Gupta and Ramarao
10
treated 14 patients with inter-vertebral disc prolapse confirmed by epidurography with10 to 15 days of continuous bed traction. Traction of 60to 80 lbs was applied through the thighs with adhesiveplaster and the foot of the bed raised 9 to 12 inches. Patientsreceived a 15 to 20 minute rest period from traction every3 to 4 hours. On a repeat epidurography after 10 to 15days of this traction treatment, 8 patients showed a re-turn to normal on a P/A study and 11 returned to normalon a lateral study.Onel et al
9
studied the effects of 15 minutes of trac-tion at 45 kg in a supine position with the legs in semiflexionon 30 patients with a disc herniation confirmed on CTscan. The patient group consisted of 18 men and 12 womenbetween ages 20 and 40. CT scans were taken before tractionand after 15 minutes of continuous traction. Of the 14patients with a median herniation, 11 showed regressionof the herniation, 2 showed an increase, and 1 showedno change. Six out of 9 patients with a posterolateralherniation showed a decrease, while 3 showed no change.Of the seven patients with a lateral herniation 4 decreasedand 3 remained the same.Traction is hypothesized to affect the position of herniated nuclear material in two ways. Traction may createa negative intradiscal pressure or even a central vacuuminside the disc, which may cause a central migration of the herniated nuclear material
3,8,9
. This hypothesis isstrengthened by Nachemson’s findings
7
: 500 Newtons of traction in supine reduce the L3-L4 intradiscal pressureto zero. It is also suggested that traction will lead totensioning of the posterior longitudinal ligament (PLL),which will then exert an anteriorly directed force on adisc herniation underneath this ligament
9
. Onel et al
9
stated that the very moderate result of traction on re-ducing lateral herniations supports the role of the PLLpushing back herniations, as these lateral herniations arenot covered by this ligament. This rationale for usingtraction is also supported by Harrington et al
11
, who foundthat traction results in an anteriorly directed force gen-erated by the PLL at the mid-body level of L1. Althoughnot directly applicable to the scenario of affecting a discherniation at mid-disc level, at least this study showedthe generation of an anteriorly directed force in the PLLby traction. We should remember that the PLL is widerat the level of the disc than at the level of the vertebralbody; it also stands off several millimeters from the posteriorsurface of the vertebral body but is intimately connectedto the disc
11
. This may lead us to assume that tractionleads to a greater anteriorly directed force at disc levelthan at mid-body level under the same traction forces.Mathews
8
’ study showed a temporary displacementof herniated material in two patients, both during andafter traction; however, it is not clear if this was the resultof the traction or the result of the prone position, theeffect of which is discussed below. Interestingly enough,both of these patients complained of pain radiating downthe lateral aspect of the leg to the lateral ankle and lat-eral foot, indicating a possible L5 nerve root problem.No herniations were shown at L4-L5 or L5-S1 in eitherpatient, however, which gives this study less external validityto justify traction as a treatment for radiculopathy re-sulting from mechanical compression by a disc hernia-tion. The study by Gupta and Ramarao
10
used a form of traction that is no longer in use. It also lacked a controlgroup showing the value of traction, bedrest and, of course,natural progression over just bedrest and natural pro-gression. The Onel et al
9
study showed regression of herniated material during traction but did not provideinformation on whether this reduction was maintainedafter traction.In conclusion, some evidence exists that continuouslumbar traction can temporarily influence the locationof herniated nuclear material. If mechanical compres-sion is indeed a source of pain in patients with discherniation, traction could have at least a temporary ef-fect on these patients’ symptoms. Based on the studiesreviewed, no differentiation can be made regarding theeffect of traction on protruded versus extruded discs.
 McKenzie exercises
McKenzie
 
exercises
12
are passive and active exercisesin beginning, middle and end-range of trunk flexion, inextension, and in a combination of sidebending and ro-tation called side-gliding. The exercises are performedweightbearing or non-weightbearing and are chosen fortheir ability to “centralize” the patients symtoms. McKenziedefines centralization as “ the situation in which painarising from the spine and felt laterally from the midlineor distally, is reduced and transferred to a more centralor near midline position when certain movements areperformed”
12
. According to McKenzie, centralization onlyoccurs in what he calls the derangement syndrome, whichis defined as “ the situation in which the normal restingposition of the articular surfaces is disturbed as a resultof the change in the position of the fluid nucleus between
Fact and Fiction of Disc Reduction: A Literature Review / 139

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